Screening questionnaires in primary care
- Test
Short questionnaires help find people who may have depression, anxiety, risky drinking, memory problems or autism, so they can be evaluated properly.
What it is
Screening questionnaires are brief, validated tools that flag people at higher probability of a condition among those without a known diagnosis. They favor sensitivity, so a positive result means ‘evaluate further’, never ‘diagnosis made’. Each has its own target, age group and cutoffs, and some also grade severity and are used to follow treatment. The items of these tools are not reproduced here; clinicians use the official validated versions, including Spanish versions.
Key facts
- PHQ-2 (the first two PHQ-9 items) is an ultra-brief first step; 3 or more leads to the full PHQ-9.
- AUDIT risk zones: 0–7 lower risk, 8–15 hazardous use, 16–19 harmful use, 20 or more possible dependence.
- AUDIT-C (0–12) is often considered positive at 4 or more in men and 3 or more in women; cutoffs vary by country and version.
- Brief cognitive screening tests (about ten minutes, scored out of 30) detect possible cognitive impairment; scores are influenced by education and language.
- EPDS (Edinburgh Postnatal Depression Scale, 10 items, 0–30) screens for depression in pregnancy and after birth and includes anxiety and self-harm items.
- M-CHAT-R/F risk bands: 0–2 low, 3–7 medium (follow-up interview), 8–20 high (refer for diagnostic evaluation and early intervention).
Common screening tools: target and what the score means
| Tool | Screens for | Who and when | Score meaning |
|---|---|---|---|
| PHQ-9 | Depression and its severity | Adolescents and adults | 0–27; 10 or more positive; also used to follow response |
| GAD-7 | Generalized anxiety (also flags panic, social anxiety, PTSD) | Adults | 0–21; 10 or more positive |
| AUDIT | Hazardous and harmful drinking, possible dependence | Adults | 0–40; 8 or more positive; zones guide the intervention |
| AUDIT-C | Risky drinking (consumption only) | Adults, quick screen | 0–12; positive about 4 or more in men, 3 or more in women |
| CAGE | Established alcohol problems | Adults | 0–4; 2 or more clinically significant; low sensitivity for risky use |
| Brief cognitive screening tests | Cognitive impairment, possible dementia | Older adults with memory concerns | Usually out of 30; lower scores suggest impairment; adjust for education |
| EPDS | Perinatal depression | Pregnancy and the first year after birth | 0–30; cutoffs about 10–13 vary by setting; self-harm item reviewed always |
| M-CHAT-R/F | Autism spectrum disorder risk | Toddlers 16–30 months, parent answers | 0–2 low, 3–7 medium, 8–20 high risk |
Clinical notes
- The NIAAA advises against CAGE for screening because it detects only people already harmed by drinking; AUDIT-C or a single heavy-drinking-day question is preferred.
- Screening only helps when a pathway exists for positives: evaluation, brief intervention, treatment or referral.
In the lab
- Validated Spanish versions exist for these tools; using unofficial translations changes their accuracy.
- Screening is followed by a diagnostic interview; the questionnaire does not replace it.
Test yourself
Think of the answer, then tap the question to see it.
What PHQ-9 total score is commonly used as a positive screen for depression?
10 or more, which corresponds to at least moderate depressive symptoms.
A patient scores 6 on the PHQ-9 but marks thoughts of self-harm. What is the next step?
Assess suicide risk at the same visit, regardless of the low total score.
Why is CAGE a weak screen for risky drinking?
It asks about consequences of drinking, so it misses people who drink heavily but have no problems yet.
At what ages is universal autism screening recommended?
At the 18-month and 24-month well-child visits.
What does the EPDS screen for?
Depression during pregnancy and after birth (perinatal depression).
Elsewhere in DurgiPedia
- Mental status: orientation, attention and screening tests
- Medicines, allergies and habits: tobacco, alcohol and other substances
- Comprehensive geriatric assessment: function, cognition, falls
Connections
Educational content on behavior and the clinical relationship; not a diagnostic or treatment guide and no substitute for assessment by a health professional. If you or someone near you is at risk, seek help now from an emergency service or a mental-health helpline.
Sources: Screen and Assess: Use Quick, Effective Methods (National Institute on Alcohol Abuse and Alcoholism (NIAAA), 2025); AUDIT : the Alcohol Use Disorders Identification Test : guidelines for use in primary health care (World Health Organization, 2001); Clinical Screening for Autism Spectrum Disorder (Centers for Disease Control and Prevention (CDC), 2025).
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Representative model, for educational purposes only.